Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

212

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 9-18

Applying Skin Traction and Caring for a

Patient in Skin Traction

Goal:The traction is maintained with the appropriate

counterbalance and the patient is free from complications

of immobility. Comments

1. Review the medical record and the nursing plan of care to
   determine the type of traction being used and care for the
   affected body part.


2. Perform hand hygiene. Put on PPE, as indicated.


3. Identify the patient. Explain the procedure to the patient,
   emphasizing the importance of maintaining counterbalance,
   alignment, and position.


4. Perform a pain assessment and assess for muscle spasm.
   Administer prescribed medications in sufficient time to allow
   for the full effect of the analgesic and/or muscle relaxant.


5. Close curtains around bed and close the door to the room,
   if possible. Place the bed at an appropriate and comfortable
   working height.

Applying Skin Traction

6. Ensure the traction apparatus is attached securely to the
   bed. Assess the traction setup.


7. Check that the ropes move freely through the pulleys.
   Check that all knots are tight and are positioned away
   from the pulleys. Pulleys should be free from the linens.


8. Place the patient in a supine position with the foot of the
   bed elevated slightly. The patient’s head should be near the
   head of the bed and in alignment.


9. Cleanse the affected area. Place the elastic stocking on the
   affected limb, as appropriate.


10. Place the traction boot over the patient’s leg. Be sure the
    patient’s heel is in the heel of the boot. Secure the boot
    with the straps.


11. Attach the traction cord to the footplate of the boot. Pass the
    rope over the pulley fastened at the end of the bed. Attach
    the weight to the hook on the rope, usually 5 to 10 pounds
    for an adult. Gently let go of the weight. The weight should
    hang freely, not touching the bed or the floor.
    12.Check the patient’s alignment with the traction.

ExcellentSatisfactoryNeeds Practice